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PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011

BRITISH COLUMBIA

REPRESENTATION AGREEMENT (SECTION 9)

Made under Section 9 of the

Representation Agreement Act.

The use of this form is voluntary. Be advised that this form may not be appropriate for use by all persons, as it provides only one option of

how a Representation Agreement may be made. In addition, it does not constitute legal advice. For further information, please consult the

Representation Agreement Act

and Representation Agreement Regulation or obtain legal advice.

This form re?ects the law at the date of publication. Laws can change over time. Before using this form, you should review the relevant

legislation to ensure that there have not been any changes to the legislation or section numbers.

The notes referenced in this Representation Agreement are found at the end of this Agreement and are provided for information only.1. THIS REPRESENT ATION AGREEMENT IS MADE BY ME, THE ADULT:

Full Legal Name of the Adult

Full Address of the Adult

2. REV OCATION OF PREVIOUS INSTRUMENTS

(See Note 1 - actions that must be taken to revoke a previous Representation Agreement)

(See Not e 2 - e?ect of revocation on previous Representation Agreements) I rev oke all of the following made by me.

Representation Agreement Act;

Representation Agreement Act.

3. REPRESENTATIVE

(See Note 3 -who may be named as Representative) I name the following person to be my Representative: Date (YYYY / MM / DD)Full Legal Name of RepresentativeFull Address of Representative

4. ALTERNA TE REPRESENTATIVE ?OPTIONAL?

(See Note 3 - who may be named as Representative) (Strike out this provision if you do not want to appoint an Alternate Representative.)

If my Representative

Representation Agreement Act,

Representation Agreement Act, at the time that I make this Representation Agreement, and

our marriage or marriage-like relationship subsequently terminates as set out in the Representation Agreement Act, or

then I name the following person to be my Alternate Representative:

Full Legal Name of Alternate Representative

Full Address of Alternate Representative

PAGE 1 OF 3

PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011

BRITISH COLUMBIA

5. EVIDENCE OF AUTHORITY OF ALTERNATE REPRESENTATIVE

(See Note 4 - statutory declaration for evidence of authority of Alternate Representative) (Strike out this provision if you are not appointing an Alternate Representative.)

A statutory declaration made by me, my Representative, or my Alternate Representative (if one is named), declaring that one of

the circumstances referenced in section 4 of this Representation Agreement has occurred, and specifying that circumstance, is

su?cient evidence of the authority of my Alternate Representative to act in place of my Representative.

6. AUTHORITY OF REPRESENTATIVE

(See Note 5 - what a Representative may and may not do)

Pursuant to section 9 (1) (a) of the Representation Agreement Act, I authorize my Representative to do anything that the Representative considers necessary in relation to my personal care and health care.

7. INTRUCTIONS OR WISHES ?OPTIONAL?

(See Note 6 - consultation with a health care provider)

The following are my instructions or wishes with respect to decisions that will be made within the areas of authority given to my Representative under this Representation Agreement:

8. EFFECTIVE DATE

This Representation Agreement becomes e?ective on the date it is executed.

PAGE 2 OF 3

PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011

BRITISH COLUMBIA

PAGE 3 OF 3

9. SIGNATURES

ADULT'S SIGNATURE

The A dult must sign and date in the presence of both Witnesses.

Date Signed (YYYY / MM / DD)

Date Signed (YYYY / MM / DD)Signature of Witness No. 1

Print Name

Address

WITNESSES TO ADULT'S SIGNATURE

WITNESS NO. 1

and W itness No. 2. Date Signed (YYYY / MM / DD)Signature of Witness No. 2

Print Name

Address

WITNESS NO. 2

standing of the Society of Notaries Public of British Columbia. and W itness No. 1. Date Signed (YYYY / MM / DD)Signature of Representative

Print Name

REPRESENTATIVEALTERNATE REPRESENTATIVE

(Strike out if an Alternate Representative is not appointed.) Date Signed (YYYY / MM / DD)Signature of Alternate Representative

Print Name

ADULT AND WITNESS SIGNATURES

REPRESENTATIVES' SIGNATURES

(See Note 8 - when a Representative may exercise authority under this Representation Agreement) If witness is a lawyer or member of the Society of Notaries Public of British Columbia, check relevant box below: lawyer member of the Society of Notaries Public of British Columbia

Print NameSignature of Adult

PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011

BRITISH COLUMBIA

STATUTORY DECLARATON FOR EVIDENCE OF

AUTHORITY OF ALTERNATE REPRESENTATIVE

This statutory declaration may be completed by the adult, the representative, or the alternate representative, as evidence of the

authority of the alternate representative to act in place of the representative. This statutory declaration would be completed if one

of the circumstances in which the alternate representative is authorized to act in place of the representative occurs to establish

the authority of the alternate representative.

CANADA

PROVINCE OF BRITISH COLUMBIA

IN THE MATTER OF the

Representation Agreement Act

re: a Representation Agreement made by naming as Representative name of Adult name of Representative

TO WIT:

Name

Full Address

SOLEMNLY DECLARE THAT:

a. I am the (strike out the descriptions that do not apply): adult who made the representation agreement representative named under the representation agreement alternate representative named under the representation agreement.

b. One of the circumstances referenced in the Representation Agreement in which the alternate representative is authorized to act

describe the speci?c circumstance resulting in the alternate representative having authority to act

AND I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and e?ect as if

made under oath.

DECLARED BEFORE ME AT

location on date Commissioner for taking A?davits for British Columbia (Apply stamp, or type or legibly print name of commissioner)

Declarant's Signature

I, of

Signature of Commissioner for taking A?davits

for British Columbia NOTES RESPECTING THIS REPRESENTATION AGREEMENT MADE UNDER SECTION 9

OF THE REPRESENTATION AGREEMENT ACT

The notes provided below are for the purpose of providing information only, and do not constitute legal advice.

These notes are prepared for the purposes of this representation agreement form. They should not be considered a complete

description of matters to be taken into account in making a representation agreement. A person making a representation

agreement, or acting as a representative or alternate representative, should consult the Representation Agreement Act

and the Representation Agreement Regulation to ensure that they understand their rights and duties. NOTE 1: Ac tions that must be taken to revoke a previous Representation Agreement

To revoke a previous representation agreement, you must also give written notice of the revocation to each

representative, each alternate representative, and any monitor named in that representation agreement.

Revocation is e?ective when this notice is given, or on a later date stated in the notice. NOTE 2: E? ect of revocation on previous Representation Agreements The revocation provision in this representation agreement will do all of the following:

NOTE 3: Who ma y be named as Representative

(a) This f orm provides for the naming of one representative and one alternate representative. If you wish to name more

than one representative to act at the same time, do not use this form.

(b) The Representation Agreement Act sets out who may be named as a representative. If an individual is appointed,

that individual must be 19 years of age or older, and must not be an individual who provides personal care or

health care services to the adult for compensation, or who is an employee of a facility in which the adult resides and

through which the adult receives personal care or health care services, unless the individual is a child,

parent or spouse of the adult. The information in this note also applies in respect of an alternate representative. NOTE 4: Sta tutory declaration for evidence of authority of Alternate Representative A statutory declaration that may be used is included with this form.

Additional evidence establishing the authority of the alternate representative to act in place of the representative may

be required for some purposes.

NOTE 5: Wha t a Representative may and may not do

The authority of a representative appointed under this representation agreement includes the power to give or refuse

consent to health care necessary to preserve life. A representative appointed under this representation agreement must not do any of the following: Health Care (Consent) and Care Facility (Admission) Act; are car ed for or supported by the adult; (Please note this list may not be complete.)

If you want your representative to be authorized to do the things on the above list, you should obtain legal advice.

In addition, under the

Representation Agreement Act

, a representative:

Mental Health Act set out in

section 11 of the Representation Agreement Act; ster ilization for non-therapeutic purposes; (Please note that this list may not be complete.) PAGE 1 OF 2PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011

NOTE 6: Consulta tion with a health care provider

If you choose to include instructions or wishes in your representation agreement about your health care, you may wish

to discuss with a health care provider the options and the possible implications of your choices.

NOTE 7: Inf ormation for witnesses

(a) The f ollowing persons may not be a witness: i. A person named in the representation agreement as a representative or alternate representative;

ii. A spouse, child or parent of a person named in the representation agreement as a representative or alternate

representative;

iii. An emplo yee or agent of a person named in the representation agreement as a representative or alternate

repr esentative, unless the person named as a representative or alternate representative is a lawyer, a member

in good standing of the Society of Notaries Public of British Columbia, or the Public Guardian and Trustee of

British C olumbia;

iv. A person who is under 19 years of age;

v. A person who does not understand the type of communication used by the adult unless the person receives

int erpretive assistance to understand that type of communication.

(b) Only one witness is required if the witness is a lawyer or a member in good standing of the Society of Notaries Public

of British Columbia.

(c) Sec tion 30 of the Representation Agreement Act provides for a number of reasons to object to the making and use of

a representation agreement. If you believe that you have grounds to make an objection at this time, you should not

witness the representation agreement and you may report your objection to the Public Guardian and Trustee

of British Columbia. NOTE 8: When a Repr esentative may exercise authority under this Representation Agreement

Before a person may exercise the authority of a representative under a representation agreement, that person must

sign the representation agreement. PAGE 2 OF 2PUBLISHED BY THE ATTORNEY GENERAL OF BRITISH COLUMBIA, SEPTEMBER 2011quotesdbs_dbs33.pdfusesText_39

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